The Oxford heart scandal in which four babies died would never have happened
if government had acted on the Bristol inquiry nearly ten years ago, experts
and campaigners have said.

The public inquiry into the deaths of dozens of babies at the Bristol Royal Infirmary recommended that children's heart surgery should not be carried out in small units.

Instead surgery should be centralised in large specialist centres which treat hundreds of cases a year, Sir Ian Kennedy, chairman of the inquiry said at the time.

But almost ten years later, a damning report has found failures at the John Radcliffe Hospital in Oxford, where four babies died after surgery.

The children's heart service at the hospital is the smallest in the country, treating only 100 cases a year, with one surgeon splitting his time between both adults and children.

As The Daily Telegraph disclosed yesterday, the report by senior doctors at the South Central Strategic Health Authority found that trust managers were aware that another national review of children's heart services, called Safe and Sustainable,would recommend small units be closed and tried to expand their service to avoid becoming one of them.

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But the attempt to boost patient numbers and carry out more complex operations went disasterously wrong when the trust took another surgeon without making adequate provision for his induction, mentoring and oversight.

The children who died had all been operated on by new surgeon Caner Salih, but the report found nothing wrong with his clinical skill and instead criticised the unit for being run in an 'idiosyncratic' way with out-of-date equipment.

Trust managers attempted to conceal the tragedy and the report warned that even during the investigation some senior doctors did not believe four deaths warranted the inquiry, the report said.

Prof Leslie Hamilton, immediate past president of the Society for Cardiothoracic Surgery, said a lack of political will stopped the Bristol Inquiry recommendations from being implemented because of the political fear of local campaigns to save heart units.

He said: "It is such a difficult political issue. There are not many votes to be won in closing children's heart centres.

"I understand why it has not happened before. It is just that it takes courage. I am hoping now there is a professional consensus and if we can keep the politicians supportive it will go through this time.

"I would like to think the units will not challenge the recommendations when they come out. I hope people will have the courage to see it through.

"I am convinced you cannot run a 24/7 service with one consultant surgeon."

He said the message was a difficult one for families who love their local hospital and want it remain unchanged. But he said for children's heart surgery, only the operation needed to be carried out in specialist centres, and the diagnostics, rehabilitation and aftercare can still be done locally.

Marie Edwards, whose daughter Jazmine Bradley, died in 1993 at the Bristol Royal Infirmary, said she was horrified to learn of the deaths in Oxford.

She founded the charity Fragile Angels to campaign for changes in the NHS after the Bristol scandal and is angry that families were assured almost ten years ago that action would be taken.

She told the Daily Telegraph: "The Bristol Inquiry was a waste of time and money, it has happened again. I feel like I have been let down.

"We understood as parents that some centres should be closed and children's heart surgery would be done in centres of excellence. If I had to take my daughter further away for a greater chance of successful surgery, I would have done that.

"I never thought in my wildest dreams that it would not be done. They told us these small units would be closed."

Suzie Hutchinson, Chief Executive of the charity Little Hearts Matter, said: "The thoughts of the Little Hearts Matter team are with the families of the children who sadly lost their lives at the Oxford unit.

"Over ten years ago, the inquiry into the failings of cardiac surgery at Bristol Children’s Hospital put forward a number of recommendations that would ensure that the unnecessary death of children with congenital heart conditions would not happen again.

"Had all these recommendations been followed through we might not be reading a report on the failings of another congenital heart unit.

"Every child and their family with a heart condition await the recommendations from the Safe and Sustainable Review of services. Local politics and financial constraints must take a back seat as the service strives to ensure that every child in the country can be assured that the hospital where they receive their treatment will only offer the very best as it is their best chance of life."

Families of children treated at the John Radcliffe have launched a campaign to save the heart unit from closure.

Kim Homewood, of the charity Young Hearts, said: "We feel very sad by the news.

"We are greatly encouraged by the arrival of the new Chief Executive Sir Jonathan Michael. We hope that he will do a fabulous job of sorting out any problems and will equipthe centre for the future so it can reopen its doors."

Katherine Fenton, director of clinical standards at the South Central SHA, which conducted the investigation into the John Radcliffe, said the unit should have learned lessons from the Bristol inquiry and from concerns raised about adult heart surgery at the hospital, following a number of deaths there between 2002 and 2005.

She said: "I think there is some evidence that a lot of lessons had been learned from both of those, but regrettably not all the lessons that we would have liked.

"What this report does is it strengthens the need for them to implement these recommendations to the full, to give us reassurances that babies are not at risk and are sufficiently cared for."